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  Citation statistics : Table of Contents
   2020| July-September  | Volume 36 | Issue 3  
    Online since October 16, 2020

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Effect of intrathecal dexmedetomidine versus intravenous dexmedetomidine on subarachnoid anesthesia with hyperbaric bupivacaine
Anshu Sharma, Nita Varghese, Ramkumar Venkateswaran
July-September 2020, 36(3):381-385
Background and Aim: Alpha-2 agonists such as dexmedetomidine when given intravenously or intrathecally as an adjuvant potentiate subarachnoid anesthesia. We studied the difference in subarachnoid anesthesia when supplemented with either intrathecal or intravenous dexmedetomidine. Material and Methods: Seventy-five patients posted for lower limb and infraumbilical procedures were enrolled for a prospective, randomized, double-blind, placebo-controlled study and divided into three groups: Group B (n = 25) received intravenous 20 mL 0.9%N aCl over 10 min followed by intrathecal 2.4 mL 0.5%bupivacaine + 0.2 mL sterile water; Group BDexIT(n = 25) received intravenous 20 mL 0.9%N aCl over 10 min followed by intrathecal 2.4 mL 0.5%b upivacaine + 0.2 mL (5 μg) dexmedetomidine; Group BDexIV(n = 25) received intravenous dexmedetomidine 1 μg/kg in 20 mL 0.9%N aCl over 10 min followed by intrathecal 2.4 mL 0.5%b upivacaine + 0.2 mL sterile water. Onset and recovery from motor and sensory blockade, and sedation score were recorded. Onset of sensory and motor blockade was assessed using Kruskal–Wallis test, whereas 2-segment regression and recovery was analyzed using ANOVA and post hoc Tukey's test to determine difference between the three groups. P value <0.05 was considered statistically significant. Results: Although onset of sensory and motor block was similar in the three groups, motor recovery (modified Bromage scale 1) and two-segment sensory regression was prolonged in Group BDexIT> Group BDexIV> Group B (P < 0.001). Patients in Group BDexITand Group BDexIVwere sedated but easily arousable. Conclusion: Intrathecal dexmedetomidine prolongs the effect of subarachnoid anesthesia with arousable sedation when compared with intravenous dexmedetomidine.
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Scheduling elective surgeries following COVID-19: Challenges ahead
Soma Ganesh Raja Neethirajan, Akilandeswari Manickam
July-September 2020, 36(3):291-296
Evolving and conflicting information about pathophysiology, clinical course and impact of corona virus disease (COVID-19) on perioperative outcome of patients has brought in new challenges while restarting elective surgeries. A roadmap to resume elective surgeries should detail timings for reopening elective surgeries, COVID-19 testing facilities, adequate PPE supplies, conservation policies for PPE and case prioritization and scheduling. We suggest a six-pronged strategy of minimizing chances of exposure, adherence to standard protocols, perioperative patient care, precautions while performing aerosol generating procedures, limiting movement of personnel within operating room and monitoring and managing health care professionals while scheduling elective surgeries to overcome the challenges this COVID-19 pandemic has brought in.
  2 4,012 368
Emergence of Telehealth for anesthesiologists in COVID-19—boon for all!
Rakesh Garg, Wasimul Hoda
July-September 2020, 36(3):417-419
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Impact of the COVID-19 pandemic on anesthesiologists in India: A cross-sectional online survey of the practices, preparedness, and mind-set
Gauri Raman Gangakhedkar, Sohan Lal Solanki
July-September 2020, 36(3):331-336
Background and Aims: India is one of the five worst hit countries in the world due to COVID-19, by the fourth week of June 2020. The impact of COVID-19 on the health practices is well-documented but there are no studies assessing its impact on anesthesiologists in India. This study aims at assessment of the impact of COVID-19 on the practices followed, the preparedness, and mindset of anesthesiologists in India. Material and Methods: Using Google forms, a cross-sectional, questionnaire-based survey was conducted between the 5th and 22nd of May, 2020, among trainees and practicing anesthesiologists, in India. The anesthesiologists were invited to participate, using their e-mail addresses and through the social media platforms such as Facebook and WhatsApp. The responses that were generated, were analyzed using SPSS version 23 (IBM, Armonk, NY). Results: Of the 707 anesthesiologists who participated, 68.3% had already worked in a COVID-19 specialty unit. Only 41.7% of the anesthesiologists felt confident that they had sufficient knowledge to deal with COVID-19 infected patients. Fear of catching the infection and infecting loved ones were important causes of anxiety, which was seen in 95% of the participants. Majority of the participants, (64.5%) did not think that elective surgical procedures could be restarted at this point. Conclusion: COVID-19 has had grave impact on anesthesiologists, on the professional and personal front, and will possibly cause near-permanent changes in the work culture. Restarting elective surgical procedures, will require meticulous planning. In spite of their self-perceived under-preparedness to combat COVID-19, an overwhelming majority of participating anesthesiologists were prepared to contribute to the management of COVID-19.
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Assessment of knowledge gaps and perceptions about COVID-19 among health care workers and general public-national cross-sectional study
Gunchan Paul, Shruti Sharma, Guneet Singh, Gurparvesh Singh, Sarit Sharma, Birinder Singh Paul, Parshotam Lal Gautam
July-September 2020, 36(3):337-344
Background: COVID-19 has impacted everyone's life and livelihood in one way or the other. Individual response to measures taken to control the rapid spread of this disease depend on their knowledge and perceptions. Hence, we proposed to evaluate responses about COVID-19 among the health care workers (HCWs) as well as general public participants (GPPs). Material and Methods: This was a cross-sectional, observational survey conducted during the peak of the pandemic. The 35-items questionnaire was prepared using Google forms and distributed through e-mails and social media. Results: The 1,026 responses comprised of 558 HCWs (54.4%) and 468 GPPs (45.6%). The most reliable source of information was TV news for 43% GPPs, whereas it was HCWs/Local health authorities for 36.8% HCWs. HCWs had sufficient knowledge regarding COVID-19, while it was relatively low among GPPs (average correct response 65% and 53%, respectively). Intra-group analysis with respect to age, sex, qualification, and socioeconomic status showed that knowledge about mode of transmission by airborne aerosols was significantly low with respect to qualification among GPPs while younger age group (<40 years) HCWs had significantly more knowledge about mode of transmission and asymptomatic carriers. Paranoia of contracting the infection was significantly higher in GPPs with upper and middle socioeconomic status and younger HCWs. Conclusion: HCWs had moderate level of knowledge, whereas GPPs had low to moderate knowledge, with large scope of improvement in both groups. Continued education, both at professional and community level will not only be helpful but also necessary to improve knowledge, avert negative attitudes and control the devastating pandemic.
  1 45,728 160
Study of risk factors and psychological impact in physicians diagnosed with COVID-19: An online, postexposure, cross-sectional survey
Jhanvi S Bajaj, Sohan Lal Solanki
July-September 2020, 36(3):345-349
Background and Aims: Healthcare workers (HCW's) who have contracted the disease while working in the hospital may have a deep psychological impact in the form of depression and anxiety, along with the stress of passing the infection to their family members. This study attempts to highlight the risk factors and psychological impact on doctors who have tested positive for coronavirus disease-2019 (COVID-19). Material and Methods: This online cross-sectional survey-based study enrolled all level doctors of all specialities of in Mumbai, India, who had tested positive for novel coronavirus. The survey questionnaire was a 26-item self-administered anonymous set of questions in English language only. This validated questionnaire was distributed by a link via Google forms for 1 week. Results: We received 51 completed responses. Most of them were (67%) postgraduate students. Forty-three (85%) respondents were working in a COVID-19 center. Twenty-three (45%) had a history of contact with these patients without proper personal protective equipment (PPE) with unknown COVID-19 status of the patient at the time of contact. Ten percent regretted their decision of becoming a doctor. Only half (51%) had family support during their illness and 45% relied on friends and colleagues in the hospital. Twenty-six percent mentioned having a low mood throughout the illness. A major portion of people (32%) having fear of severe illness and death. Conclusion: Medical doctors working in direct contact with confirmed cases of COVID-19 are at increased risk of contracting the infection and it has a major impact on physical and mental health of medical doctors.
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A new approach to airway assessment— “Line of Sight” and more. Recommendations of the Task Force of Airway Management Foundation (AMF)
Rakesh Kumar, Sunil Kumar, Anil Misra, Neera G Kumar, Akhilesh Gupta, Prashant Kumar, Divya Jain
July-September 2020, 36(3):303-315
Assessment of airway is recommended by every airway guideline to ensure safe airway management. Numerous unifactorial and multifactorial tests have been used for airway assessment over the years. However, there is none that can identify all the difficult airways. The reasons for the inadequacy of these methods of airway assessment might be their dependence on difficult to remember and apply mnemonics and scores, inability to identify all the variations from the “normal” , and their lack of stress on evaluating the non-patient factors. Airway Management Foundation (AMF) experts and members have been using a different approach, the AMF Approach, to overcome these problems inherent to most available models of airway assessment. This approach suggests a three-step model of airway assessment. The airway manager first makes the assessment of the patient through focused history, focused general examination, and focused airway assessment using the AMF “line of sight” method. The AMF “line of sight” method is a non-mnemonic, non-score-based method of airway assessment wherein the airway manager examines the airway along the line of sight as it moves over the airway and notes down all the variations from the normal. Assessment of non-patient factors follows next and finally there is assimilation of all the information to help identify the available, difficult, and impossible areas of the airway management. The AMF approach is not merely intubation centric but also focuses on all other methods of securing airway and maintaining oxygenation. Airway assessment in the presence of contagion like COVID-19 is also discussed.
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Protocolized approach to a COVID-19 parturient undergoing a cesarean section – A case report
Kompal Jain, John Alen, Subodh Kumar, Sukanya Mitra
July-September 2020, 36(3):407-410
The health care workers working in the operation theater (OT) face many unique challenges to deal with the corona virus disease (COVID-19) patients undergoing surgery. We hereby report the management of a COVID-19 parturient undergoing cesarean section in the dedicated COVID health center. Patient care of this special and vulnerable subset of population with least exposure of COVID-19 to health care worker was the cornerstone of the management. We have summarized some of the important precautionary measures which were taken during cesarean section to minimize exposure and genuine use of resources in this pandemic. To conclude, despite Personal Protective Equipment (PPE), precautionary measures and strategies are of utmost importance and should be opted so as to lower the virus contagion risk.
  - 840 115
Surgical safety checklist in the COVID era
Reshma P Ambulkar, Pankaj Singh, Jigeeshu Divatia
July-September 2020, 36(3):289-290
  - 2,250 255
Are the users of Valved N95 masks 'innocent spreaders' of COVID-19?
Ashvind Bawa, Gurpreet S Wander, Ramit Mahajan
July-September 2020, 36(3):410-411
  - 1,261 82
SARS- CoV-2 infection presented as acute exacerbation of bronchial Asthma
Parul Raina, Dalim K Baidya, Rahul K Anand, Bikash R Ray, Rajeshwari Subramaniam, Souvik Maitra
July-September 2020, 36(3):412-413
  - 707 99
A simple solution to fogging inside goggles used as a part of personal protective equipment
Rahul K Anand, Bikash R Ray, Dalim K Baidya, Sulagna Bhattacharjee, Souvik Maitra
July-September 2020, 36(3):413-414
  - 1,519 108
Re-exploring the online surveys: Research tools in COVID times
Chitta R Mohanty, Rakesh Vadakkethil Radhakrishnan, Mantu Jain
July-September 2020, 36(3):414-415
  - 850 75
Tele-Preanesthetic check-ups (TelePAC) during COVID-19: Apprehensions and possibilities
Divya Srivastava, Sohan Lal Solanki, Suruchi Ambasta, Abhilash Chandra
July-September 2020, 36(3):415-417
  - 1,274 107
Convalescent plasma therapy in COVID 19: Every dark cloud has a silver lining
Kunal Deokar, Gopal Chawla, Benhur Joel Shadrach, Naveen Dutt
July-September 2020, 36(3):419-423
  - 1,015 148
Art, science, and aequanimitas: Pillars of modern anesthesia practice
Ameya Karanjkar, Rohan Magoon, Brajesh Kaushal, Poonam M Kapoor
July-September 2020, 36(3):423-424
  - 475 54
Combined dexmedetomidine and glycopyrrolate infusion: Have we found our solution?
Rakhi Bansal, Mritunjay Kumar, Harsha Makam
July-September 2020, 36(3):424-425
  - 794 75
Usefulness of dexmedetomidine as an intravenous adjuvant
S Parthasarathy
July-September 2020, 36(3):425-426
  - 469 58
Response to Queries on “Effects of intravenous dexmedetomidine on spinal anaesthesia and sedation – a comparison of two different maintenance infusions.”
Pritee H Bhirud, Shrividya Chellam
July-September 2020, 36(3):426-427
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Optimal utilization of sedative and analgesic potential of dexmedetomidine in a child with severe kyphoscoliosis for vitreoretinal surgery
Kanil R Kumar, Zakia Saeed, Anjolie Chhabra
July-September 2020, 36(3):427-428
  - 558 67
Unusual cause of airway obstruction after nasal intubation with a preformed endotracheal tube
Ranju B Bansal, Mridul M Panditrao, Minnu M Panditrao
July-September 2020, 36(3):429-430
  - 456 81
A rational approach to manage surgical procedures in COVID Era – A perspective based on experience in a private referral hospital
Rama Gupta, Bishav Mohan, Kamakshi Garg, Ashima Taneja, Satpal S Virk, Anju Grewal, Rajesh Mahajan
July-September 2020, 36(3):325-330
Background and Aims: COVID-19 disease has imposed challenges in caring for non-Covid elective surgical patients. As elective surgeries become essential, we propose to evaluate our approach and outcomes of surgical procedures performed during the initial period of COVID-19 pandemic so as to provide a road-map for safer approach. Material and Methods: We retrospectively evaluated outcomes in patients who underwent essential elective and emergency surgeries during the 5-week period between April 18, 2020 and May 28, 2020. All patients were screened at the front desk on their arrival to identify possible exposure to SARS- CoV-2. Nasopharyngeal swab of patients requiring hospital admission was tested for COVID-19 by quantitative RT-PCR. Patients needing essential elective surgery were taken up for surgery if they tested negative for COVID-19. Emergency procedures were undertaken in a demarcated theatre for COVID after taking level-3 protection without delay. The clinical data was reviewed and analysed. Results: A total of 764 surgical procedures were conducted, of which 70.7% were elective essential surgeries, with 95.4% of these patients being discharged in stable healthy condition. Approximately 23% of the elective and 26% of the emergency surgeries was categorised in the surgical difficulty category III and majority of these were performed under general anesthesia. Postoperative mortality was 1.04%, but the overall mortality rate was approximately 2.5%. Only two patients (0.3%) tested positive for COVID-19 in our series. Conclusion: A robust preoperative screening and testing can enable safe scheduling of essential elective surgeries.
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Avoidance of deep anesthesia and artificial airways in 1000 neonates and infants using regional anesthesia: A retrospective observational analysis
Vrushali C Ponde, Dilip N Chavan, Ankit P Desai, Anuya A Gursale, Vinit V Bedekar, Kiran A Puranik
July-September 2020, 36(3):386-390
Background and Aims: Current concerns related to the anesthetic neurotoxicity have brought a renewed interest in regional anesthesia. Regional anesthesia reduces the need for opioids and inhalational anesthetics. The immaturity of the neonatal and infant nervous system may render them more prone to neurotoxicity. We describe our technique of anesthesia, which minimizes the exposure to general anesthetics and reduces airway instrumentation because the operability is rendered by the regional block. Material and Methods: This was a retrospective case series of neonates and infants undergoing common surface surgeries. We describe our technique of anesthesia where regional blocks are the mainstay. We also put up the data pertaining to block effectiveness, technique, end-tidal sevoflurane concentration and complications. Results: One thousand patients, including neonates and infants, received central and peripheral nerve blockade. The failure rate in upper extremity blocks 0% without complications. 86.12% were given under ultrasonography (USG) guidance and 13.89% were given with peripheral nerve stimulation. The failure rate of sciatic block single shot and continuous was 0%. 92.53% were given with USG guidance while 7.46% received sciatic with nerve stimulation technique. Failure rate of caudal epidural block was 0. 78% requiring a rescue analgesic, 1.4% had blood in the needle. Out of the caudals, 33.33% were done with USG guidance and 66.67% blocks were given with traditional techniques. Out of the 322 penile + ring blocks given by traditional method, 1 block failed requiring rescue analgesics. The mean sevoflurane concentration was 1.2 +/- 0.32. Conclusion: It is feasible to conduct surface surgeries in the most vulnerable population such as neonates and infants under regional anesthesia without intubation and airway instrumentation.
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Comparison of hemodynamic responses to laryngoscopy and intubation using Macintosh or McCoy or C-MAC laryngoscope during uniform depth of anesthesia monitored by entropy
M Rajasekhar, Monu Yadav, Dilip Kulkarni, R Gopinath
July-September 2020, 36(3):391-397
Background and Aims: Laryngoscopy forms an important part of general anesthesia and endotracheal intubation. The aim of the present study was to compare the hemodynamic responses to Laryngoscopy and Intubation using Macintosh or McCoy or C-MAC Laryngoscope with M-Entropy module monitoring to ensure uniform and adequate depth of anesthesia, during and after intubation. Material and Methods: A prospective, randomised, comparative study was done and patients included were of 18 to 60 years, ASA (American Society of Anesthesiologist) physical status I and II of both sexes undergoing elective surgery under general anesthesia. They were assigned to three groups using simple randomisation, after securing IV (intravenous) access, standard monitoring and Entropy leads were attached. General anesthesia was administered with glycopyrrolate 0.1 mg, fentanyl 2 ug/kg and intravenous thiopentone, 4 mg/kg. Adequate muscle relaxation was achieved with atracurium 0.6 mg/kg IV. By titrating isoflurane concentration, Entropy maintained between 40 and 60, orotracheal intubation done, with Macintosh or McCoy or C-MAC blades according to simple randomisation. Size of laryngoscope blade, time taken for laryngoscopy and intubation were noted. Heart rate, blood pressure, RE (Response Entropy) and SE (State Entropy) were noted before and during induction and laryngoscopy and post intubation up to 5 minutes. Statistical analysis done using NCSS 9 version 9.0.8 statistical software. Results: Hemodynamic responses during laryngoscopy and intubation using Macintosh or McCoy or C-MAC laryngoscope were statistically insignificant (p > 0.05) between the three groups, provided the depth of anesthesia is maintained constant. Conclusions: It is the depth of anesthesia that decides the magnitude of hemodynamic responses and not the choice of laryngoscope.
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A comparative evaluation of different doses of dexmedetomidine as an adjuvant to bupivacaine in transversus abdominis plane block for postoperative analgesia in unilateral inguinal hernioplasty
Rathi Mitesh Madangopal, Aashish Dang, Megha Aggarwal, Jay Kumar
July-September 2020, 36(3):398-406
Background and Aims: The present study is designed to evaluate addition of two different doses of dexmedetomidine (0.25 mcg/kg and 0.5 mcg/kg) as an adjuvant to bupivacaine in transversus abdominis plane block for post-operative analgesia in patients undergoing unilateral inguinal hernioplasty. Material and Methods: A total of 90 patients scheduled to undergo elective unilateral open inguinal hernioplasty were divided into three groups in a randomized triple blind way. In group B (n = 30), patients received TAP block using 22 ml of solution, consisting of 20 ml of 0.25% bupivacaine and 2 ml of normal saline; in group BD1 (n = 30), patients received TAP block using 22 ml of solution, consisting of 20 ml of 0.25% bupivacaine and dexmedetomidine 0.25 mcg/kg dissolved in 2 ml of normal saline; while in group BD2 (n = 30), patients received TAP block using 22 ml of solution, consisting of 20 ml of 0.25% bupivacaine and dexmedetomidine 0.5 mcg/kg dissolved in 2 ml of normal saline. Results: Time to first analgesia was significantly prolonged in group BD2 (874.48 ± 118.28 minutes) as compared to BD1 (536.5 ± 60.35 minutes) and B (341.5 ± 46.22 minutes) (P < 0.0001). Total consumption of diclofenac was also reduced in BD2 (80.17 ± 19.34 mg) as compared with B (150 ± 0 mg) and BD1 (147.5 ± 13.69 mg) (P < 0.001). Patients in dexmedetomidine group were more sedated at 1-hour (P < 0.05). None of our patients required any intervention for hemodynamic changes which were significantly more in dexmedetomidine group. Conclusion: Dexmedetomidine in a dose of 0.5 mcg/kg is better than dose of 0.25 mcg/kg as an adjuvant to 0.25% bupivacaine in transversus abdominis plane block for post-operative pain relief in unilateral inguinal hernioplasty. However, it causes mores sedation and hemodynamic changes.
  - 565 102
A survey of physicians' appreciation and knowledge about airway safety measures in the wake of COVID-19 pandemic
Sakshi Duggal, Bhuvna Ahuja, Partha S Biswas, Anirban Hom Choudhuri
July-September 2020, 36(3):350-358
Background and Aims: The implementation of safety measures during airway management is a major concern to prevent COVID-19 transmission during pandemic. Various guidelines and advisories are in vogue to ensure safe practices. However, their success depends on the caregivers' knowledge and understanding. This survey was conducted to assess the knowledge and safety concerns amongst physicians towards airway management in the background of COVID-19 pandemic. Material and Methods: A survey instrument of thirty questions covering three timelines of airway management viz. 'before', 'during' and 'after' airway intervention was created. The questionnaire was electronically mailed to the eligible physicians over a period of one month via a web-based platform and the responses were analyzed. The responses were depicted numerically as percentage. A multiple discriminant analysis was used to test the accuracy of responses after adjusting for common variables. Results: Out of 407 responses, 300 were eligible for analysis. The respondents with correct answers to questions with single correct response were 46%, 69% and 57.3%, along the three timelines and the respondents with more than 75% correct responses in questions with multiple correct responses were 49%, 58% and 31% along the same timelines. About 75% of the participants became aware of transmission through aerosols aftermath pandemic. About two-third of the participants had knowledge about the safety guidelines and recommendations. Majority of the respondents were aware of the safety measures 'during airway intervention'. Conclusion: Our study found satisfactory knowledge and appreciable concern among the practicing physicians regarding airway safety measures in the wake of COVID-19 pandemic. However, more physicians were aware about the measures required to be adopted 'during' airway intervention. The survey highlights the need for a more focused training of the caregivers about safety measures 'before' and 'after' airway intervention.
  - 968 97
A mixed-method study to assess the knowledge-practice gap regarding hand hygiene among healthcare providers in a tertiary care hospital
Manvi Sagar, Sarit Sharma, Anurag Chaudhary, Shruti Sharma
July-September 2020, 36(3):359-365
Background and Aims: The burden of healthcare-associated infections (HAIs) is very high and compliance with infection control practices is poor in low and middle-income countries (LMICs). Hand hygiene (HH) being the most important measure to prevent HAIs, the present study was conducted to assess the gap in knowledge, perceptions, and practices of healthcare providers (HCPs) regarding HH and also to know the barriers in adherence to HH practices. Material and Methods: This questionnaire-based cross-sectional study was carried out among 400 HCPs for 1 year. HH practices of HCPs were observed by a trained investigator followed by filling of the preformed proforma by HCPs. The quantitative data were analyzed using Epi info (Version 7) statistical software while qualitative analysis was done to generate themes. Results: The compliance to HH was higher among nurses (78.3%) than consultants (49.5%) and residents (39.1%). Compliance was more in ICUs (71.4%) than wards (58.3%). Knowledge about HH was found to be 73.8% among consultants and 71.6% among residents, whereas HH opportunities availed by them were only 49.5% and 39.1%, respectively revealing a knowledge-practice gap. The main barriers to adherence to HH as perceived by HCPs were lack of awareness despite adequate knowledge, time constraints, heavy workload, and so on. Conclusions: In our study, we found that despite adequate knowledge, consultants and residents showed lower compliance with HH practices as compared to nurses. Increasing awareness regarding HH guidelines through frequent sensitization sessions decreased workload, and strict surveillance may help in bridging the knowledge-practice gap.
  - 1,106 122
Preemptive local anesthetic infiltration reduces opioid requirements without attenuation of the intraoperative electrical stapedial reflex threshold in pediatric cochlear implant surgery
Wahba Z Bakhet, Hassan A Wahba, Lobna M El Fiky, Hossam Debis
July-September 2020, 36(3):366-370
Background and Aims: Total intravenous anesthesia using remifentanil provides good surgical condition without affecting the intraoperative electrical stapedial reflex threshold (ESRT). However, remifentanil results in hyperalgesia and increases postoperative opioid requirements. Local anesthetic infiltration is alternative methods to opioid for providing analgesia. However, otologists avoids its use as it can abolish the ESRT. We investigated the effect of the preemptive local anesthetic infiltration on intraoperative ESRT and opioid requirements in pediatric cochlear implant surgery performed under TIVA. Material and Methods: Prospective, randomized, double-blinded, controlled study including 70 child undergoing cochlear implant under TIVA were randomly assigned to a local anesthesia (LA group, n = 35) or control (CT group, N = 35). The primary outcome was the total tramadol consumption during the first 24 h postoperative, and the secondary outcomes were time to first analgesia request, postoperative pain scores, the ESRT and, propofol and remifentanil requirements. The incidence of postoperative vomiting was recorder as well. Results: The total tramadol consumption during the first 24 h after surgery was significantly less in the LA group than in CT group (8.25 [4.3] vs. 16.5 [6.57] mg, P< 0.01). The time to first analgesic request was significantly prolonged in the LA group as compared with the CT group [8 [2–12] vs. 3 [0–8] h, P< 0.01). The postoperative Faces, Legs, Activity, Cry Consolability pain scores were significantly lower in the LA group at 15 min, 30 min, 2, 4 and 6 h postoperative. Mean remifentanil infusion rate [mean (standard deviation)] was significantly higher in in the CT group than in the LA group [0.7 (0.3) vs. 0.5 (0.2) μg/kg/min; P= 0.001).The ESRT response, propofol requirements, and the incidence of postoperative vomiting had no significant differences between both groups. Conclusion: Preemptive local anesthetic infiltration reduced opioid requirements without attenuation of the ESRT in pediatric cochlear implant surgery performed under TIVA.
  - 813 102
Comparison of efficacy of thoracic paravertebral block with oblique subcostal transversus abdominis plane block in open cholecystectomy
Seema Jindal, Gurkaran Kaur Sidhu, Gurpreet Kaur Baryha, Baltej Singh, Samiksha Kumari, Rupali Mahajan
July-September 2020, 36(3):371-376
Background and Aims: Sensory afferent nerve branches of lower six thoracic and upper lumbar nerves innervate the anterior abdominal wall and are the therapeutic focus of local anesthetics to provide analgesia for the abdominal surgical incision. Central neuraxial and regional analgesia can provide better control of pain due to right subcostal incision used in open cholecystectomy and attenuate the need for opioids. The earlier studies which showed the benefit of the thoracic paravertebral block (TPVB) for analgesia after upper abdominal surgeries did not compare TPVB with oblique subcostal transversus abdominis plane (OSTAP) block. Therefore, the current study compares the analgesic efficacy of TPVB and OSTAP block in open cholecystectomy. Material and Methods: Seventy consenting adults scheduled for open cholecystectomy were allocated to one of the two groups: ultrasound-guided TPVB (Group I) and ultrasound-guided OSTAP block (Group II). The primary objective of this study is to assess and compare tramadol consumption in 48 h in both the groups along with VAS in post anesthesia care unit, and then at 2, 4, 6, 8, 12, 24, and 48 h. The secondary objective of the study is to assess the incidence of PONV. Results: The number of doses of rescue analgesia required was less in Group I when compared with Group II (P < 0.001). Patients in Group I had significantly lower pain scores than Group II. Although in the initial 8 h, both groups had comparable pain scores, after 8 h, these scores were significantly lower in patients in Group I. Less postoperative nausea and vomiting was seen in Group I patients (11.7%) in comparison to Group II (18.1%). Conclusion: Ultrasound-guided TPVB is superior to OSTAP block because of its association with decreased postoperative opioid consumption, lower VAS score, and reduction in opioid-related side effects. Thus, it should be strongly considered as a part of multimodal analgesia regimen in upper abdominal surgeries.
  - 973 113
The comparison of effects of fentanyl and dexmedetomidine as adjuvants to ropivacaine for ultrasound-guided transversus abdominis plane block for postoperative pain in cesarean section under spinal anesthesia –A randomized controlled trial
Bincy Joseph, Sunitha K Zachariah, Saramma P Abraham
July-September 2020, 36(3):377-380
Background and Aims: Transversus abdominis plane (TAP) block has been effectively used for anterior abdominal wall analgesia. The aim of the study was to compare the duration of analgesia produced by two drugs fentanyl and dexmedetomidine as adjuvants to ropivacaine in TAP block under ultrasound-guidance after lower segment cesarean section in a randomized controlled trial. Methods: Sixty-four women of American Society of Anaesthesiologists (ASA) physical status II coming for cesarean sections were randomized to receive TAP blocks on each side of the abdomen using the local anesthetic drug 20 ml of 0.5% ropivacaine with either fentanyl 25 mcg or dexmedetomidine 25 mcg. A ten point numerical pain score was done at baseline, at 1 h and then at intervals of 4 h postoperatively. The hemodynamic parameters such as heart rate, blood pressure, and pulse oximetry were also monitored as above. The time to first analgesia demand from the time of the block and the total analgesic consumption were recorded. The statistical analysis was done by Mann-Whitney U test and the analgesics consumption by using Chi-square test with R software. Results: Our primary end-point was to assess the duration of analgesia produced by fentanyl added to ropivacaine for ultrasound-guided TAP block, which were 125 min with Q1–Q3 as 110–180 and dexmedetomidine 130 min with Q1–Q3 as 105–161 (P value = 0.47). The amount of analgesics used in the postoperative period in both the groups were analyzed using the Chi-square test not found to have any significant difference between both the groups (P-value = 0.512). Conclusion: Fentanyl and dexmedetomidine as adjuvants to ropivacaine in ultrasound-guided TAP block were equally effective in both prolongation of analgesia and reducing the total consumption of analgesics.
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Shared decision making in peri-operative medicine: Miles to go in Indian scenario
GV Krishna Prasad
July-September 2020, 36(3):316-324
Shared Decision Making (SDM) in peri-operative medicine is increasingly encouraged as an ideal model of treatment decision making in the medical encounter. Moreover, it has the potential to improve the quality of the decision-making process for patients and ultimately, patient outcomes. This review focuses on several published literature on SDM in peri-operative medicine, its Implementation, barriers faced by Patient and the Provider, Myths regarding SDM and current scenario of SDM in India. Within the anesthetic community, patient consent is vigorously guided. However, this community suffers from lack of advancements in implementing the patient-focused rather than doctor-focused characteristics of SDM. Out of the several barriers, the most common barrier towards the implementation of SDM is the lack of time from the provider community. Within the anesthesia domain, the consultations discussed directly preceding the surgery do not pursue the customary and highly organized stages of typical outpatient consultations. Under these backgrounds and to be successfully implemented, it becomes imperative to begin the process of SDM pre-operative assessment clinic targeting both the high- and low-risk patients. It is critical to summarise that SDM does not end at the time of anesthesia for the peri-operative healthcare professional, but it gets to carry forward until patient discharge. Therefore, it is carried as the Pinnacle of Patient-Centred Care.
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Anesthesia and Alzheimer's: A review
Jeffrey Y Sun
July-September 2020, 36(3):297-302
As early as 1955, it was Bedford who provided description of cognitive changes in elderly patients following anesthesia and surgery. Reports of individuals with catastrophic, non-stroke-related decline in cognitive functions following anesthesia and surgery lead to a perception in the lay population that anesthesia and surgery have the potential to greatly exaggerate the progression of dementia, particularly Alzheimer's disease (AD). There is a concern that anesthesia and surgery could cause irreversible impairment, leading to AD. This could also explain the accelerated decline in patients with mild cognitive impairment. We seek to explore the relevant literature to determine whether a correlation exists and then propose a possible pathophysiologic mechanism.
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